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WELL HEAD INSPECTION CHECKLIST AND REPAIR ORDER <br /> Client r `�� Site# '72�-/��� Inspection date <br /> Site address F?-e'`��z" � _ Inspected by <br /> 7 �GG J�7> � BTS Event# <br /> 1 Lid on the box? Yes No 5 Water standing in the well box? 7 Can cap be pulled loose? <br /> 2 Lid whole? 5a Standing above well top? S Can cap seal out water? <br /> 3 Lid secure? 5b Standing below well tope 9 Padlock present? <br /> 4 Lid seal intact? 5c Water even with top of well cap? 10 Padlock found locked? <br /> 6. Well cap/plug present'? 11 Padlock functional? <br /> P <br /> heck box if no defrcrences were found. Note below deficiencies you were able to correct <br /> Well I.D Deficiency Corrective Action Taken <br /> ` 2 -� 0 <br /> Note below all deficiences that could not be corrected and still need to be corrected <br /> BTS Office assigns or Date Date <br /> Well I.D. Persisting Deficiency defers Correction to: assigned corrected <br /> Office review and assignments made by date <br /> Blaine Tech Services, Inc File WELLCHK.s <br />